- Confused patient died after consuming alcohol rub from a dispenser near his bed
- NHS Improvement seeking design solutions to prevent further deaths
- Trust issues staff with mini bottles of hand wash and introduces lockable dispensers
NHS England’s medical director is considering new safety measures for acute trusts after a patient died from drinking alcohol rub.
Professor Sir Bruce Keogh said NHS Improvement is exploring designs to limit the amount of alcohol gel released from dispensers after John Haughey 76, consumed a large amount of hand wash from a dispenser near his bed at Hull Royal Infirmary in 2015. Mr Haughey, who may have been developing dementia, was confused at the time.
Sir Bruce set out options that are being explored at a national level to prevent a repeat of the incident in a letter released to HSJ yesterday.
Since Mr Haughey’s death, Hull and East Yorkshire Hospitals Trust has introduced lockable wall mounted dispensers and issued staff with personal mini bottles of hand wash.
Although satisfied with the trust’s action, Professor Paul Marks, senior coroner for Hull and the East Riding, contacted NHS England in April to prevent future deaths after saying he was “not convinced” the risk to patients from hand gels had been shared across the NHS.
In his response to the coroner, seen by HSJ, Sir Bruce said organisations had already been issued with “significant guidance” underlining the need for risk assessments when gels were used near vulnerable patients.
However, Sir Bruce said “the continued persistence of these problems” meant regulators were considering further action, including the introduction of dispensers limiting the amount of gel released in NHS settings.
Sir Bruce said: “Clearly, product redesign is a complex process and the first step will be to identify if such gel dispenser products already exist that may be suitable for purchase in NHS settings.”
The inquest into Mr Haughey’s death recorded a narrative conclusion on 10 February and the cause of death was given as bronchopneumonia, acute alcohol toxicity and acute delirium.
Mr Haughey, who may have been developing vascular dementia, was admitted to Hull Royal Infirmary in September 2015 after suffering nine months of increasing confusion.
He drank hand wash containing a 75 per cent concentration of ethyl alcohol from a dispenser on 6 September.
The inquest heard Mr Haughey was taken to intensive care but his condition deteriorated and he died on 12 September.
In his letter to NHS England, Professor Marks said: “There is a tension between the need to prevent cross infection in the hospital setting and the possibility of confused patients consuming preparations used to clean clinicians’ hands.
“Whilst incidents such as John Haughey’s are thankfully rare, it is my view that similar tragedies could occur given the now ubiquitous presence of such hand washing gels and their dispensers.
“I am not convinced that information about this incident has been disseminated as widely within the NHS, the public sector in general and private sectors as it should be.
“Action should be taken to prevent future deaths and I believe NHS England has the power to take such action.”
Sir Bruce told the coroner NHS England could not directly influence the wider use of alcohol based gels in public although he had flagged the risk through the Medicines and Healthcare Products Regulatory Agency.
In addition to exploring dispenser designs, he said NHS Improvement, responsible for patient safety alerts, was collating expert guidance to standardise the care of patients suffering accidental ingestion.
NHS Improvement would update the coroner on both steps “as developments emerge”, Sir Bruce said.
Mr Haughey’s family has launched legal action.
Hull and East Yorkshire Hospitals Trust offered its condolences to the family but declined to comment further.
Letter seen by HSJ
- HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
- Medicines and Healthcare Products Regulatory Agency
- NHS East Riding of Yorkshire CCG
- NHS England (Commissioning Board)
- NHS Hull CCG
- NHS Improvement
- NHS North East Lincolnshire CCG
- NHS North Lincolnshire CCG
- NHS Scarborough and Ryedale CCG
- NHS Vale of York CCG
- Patient experience
- Patient safety
- Yorkshire and the Humber